Rifat OZMEN, Inayet GUNTURK, Aydın TUNCAY, Şaban KELEŞOĞLU, Cevat YAZICI, Osman Okan ÖZOCAK, Kutay TAŞDEMİR

POSTOPERATİF ATRİYAL FİBRİLASYON GELİŞİMİNİ ÖNGÖRMEDE ALBUMİN / GLOBULİN ORANI ERKEN PREDİKTİF BİR BELİRTEÇ OLABİLİR Mİ ?

AMAÇ: Atriyal fibrilasyon (AF), klinik pratikte yaygın olarak karşılaşılan bir aritmi çeşidi olup açık kalp cerrahisi sonrası da sıklıkla ortaya çıkan iyi tanımlanmış bir komplikasyondur. Postoperatif AF (POAF), koroner arter baypas greftleme (KABG) sonrası ikinci günde en yüksek insidansa sahip olmak üzere 2-4 gün içinde hastaların % 5-40’ında rapor edilmiştir. POAF’ın patofizyolojisi tam olarak anlaşılamamıştır. Bunun en önemli nedeni, patolojiye katılan çok sayıda faktörün gösterilmiş olmasıdır. Bu faktörler, kardiyopulmoner baypas (KPB)’ın non-fizyolojik doğası, enflamatuvar cevap, kardiyoplejik arrest, kardiyak manipülasyonlar, miyokardiyal iskemi-reperfüzyon hasarı ve kullanılan farmakolojik ajanlar olabilir. Albumin ve globulinler, sistemik enflamatuvar sürece katılan iki major serum protein kompanentidir. Serum albumin düzeyi kronik enflamasyonla yakından ilişkili iken, globulinlerin artmış seviyeleri de kronik enflamatuvar cevabın bir belirteci olarak işlev görür ve çeşitli proenflamatuvar sitokinlerin kümülatif maruziyeti yansıtması açısından önemlidir. Bu çalışmada Albumin globulin oranı (AGO)’nın, hem bağımsız olarak hem de POAF gelişimi için öne sürülen diğer risk faktörleri ile birlikte değerlendirilerek, POAF gelişimindeki prediktif öneminin araştırılmasını amaçladık.GEREÇ VE YÖNTEM: Erciyes Üniversitesi Tıp Fakültesi Kardiyovasküler Cerrahi Ana Bilim Dalında 01.01.2018 - 31.12.2020 tarihleri arasında izole KABG cerrahisi geçiren 288 hastanın (62 kadın ve 226 erkek) verileri retrospektif olarak incelendi. Hastaların preoperatif ve postoperatif kan değerleri, bazal karakteristik özellikleri ve intraoperatif parametreleri değerlendirildi. Çoklu regresyon analizi, Backward: Wald metoduna göre yapıldı.BULGULAR: 288 hasta içerisinde . ortanca yaş 63 (56-69) yıl olup AF gelişen grupta ise ortanca yaş, 66,0 (61,2-72,0) yıl (P: 0.003)’dır. POAF gelişme durumlarına göre hastalar gruplandırıldıklarında, iki grup arasında yaş (P: 0.003), total anastomoz sayısı (P:0.004) ve safen ven grefti (SVG) distal anastomoz sayısı (P: 0.006), preoperatif platelet sayısı (P:0.027), kan üre azotu (BUN) (P:0.004), kreatinin (P:0.001) ve postoperatif BUN (P:0.005) değerleri açısından istatistiksel olarak anlamlı fark olduğu saptanırken, preoperatif ve postoperatif AGO değerleri (P: 0,140, P: 0.313) bakımından gruplar arasında istatistiksel açıdan fark olmadığı saptandı. Çoklu regresyon analizindeki Backward: Wald metoduna göre son basamakta, POAF gelişen hastalarda; yaş, preoperatif platelet sayısı, kreatinin seviyeleri, periferik arte hastalığı (PAH) varlığı ve total anastomoz sayısı bağımsız risk faktörleri olarak bulundular.SONUÇ: Bu çalışmada, AGO değerleri ve POAF gelişimi arasında istatistiksel olarak anlamlı bir ilişki tespit edilmedi. KABG uygulanan hastalarda POAF’ın ortaya çıkışında hem genel popülasyonda, hem de ayrı bir alt grup olarak Diabetes Mellitus hastalarında preoperatif kreatinin seviyesi ve platelet sayılarının değerlendirilmesinin önemli olduğu bulunmuştur. Ayrıca, preoperatif kreatinin, yaş, total anastomoz sayısı ve preoperatif platelet sayısı bağımsız risk faktörleridir.

Anahtar Kelimeler:

Koroner arter baypas greftleme, Postoperatif atriyal fibrilasyon, Albümin, Globulin, Albümin globülin oranı

COULD ALBUMIN / GLOBULIN RATIO BE AN EARLY PREDICTIVE MARKER IN PREDICTING THE DEVELOPMENT OF POSTOPERATIVE ATRIAL FIBRILLATION ?

OBJECTIVE: Atrial fibrillation (AF) is a widely encountered type of arrhythmia in clinical practice and is a well-defined complication that occurs frequently after open heart surgery. Postoperative AF (POAF) has been reported in 5-40% of patients within 2-4 days with the highest incidence on the second day after coronary artery bypass grafting (CABG) surgery. The pathophysiology of POAF is not fully understood. The most important reason for this is that many factors involved in pathology have been shown. These factors may be the non-physiological nature of cardiopulmonary bypass (CPB), inflammatory response, cardioplegic arrest, cardiac manipulations, myocardial ischemia-reperfusion injury and the pharmacological agents used. Albumin and globulins are two major serum protein components involved in the systemic inflammatory process. While serum albumin level is closely associated with chronic inflammation, increased levels of globulins also serve as a marker of chronic inflammatory response and are important in reflecting the cumulative exposure of various proinflammatory cytokines. In this study, we aimed to investigate the predictive significance of Albumin globulin ratio (AGO) in the development of POAF by evaluating it both independently and together with other risk factors suggested for the development of POAF.MATERIAL AND METHODS: The data of 288 patients (62 females and 226 males) who underwent isolated CABG surgery between 01.01.2018 and 31.12.2020 in the Cardiovascular Surgery Department of Erciyes University Faculty of Medicine were retrospectively analyzed. Preoperative and postoperative blood values, baseline characteristics and intraoperative parameters of the patients were evaluated. Multiple regression analysis was performed using the Backward: Wald method.RESULTS: The median age among 288 patients was 63 (56-69)years, and the median age in the AF-developing group was 66.0 (61.2-72.0)years (P: 0.003). When the patients were grouped according to their POAF development status, there was a statistically significant difference between two groups in terms of age (P: 0.003), total anastomosis number (P: 0.004), Saphenous Vein graft (SVG) distal anastomosis number (P: 0.006), preoperative platelet number (P: 0.027), Blood Urea Nitrogen (BUN) (P: 0.004), creatinine (P: 0.001) and postoperative BUN (P: 0.005) values, while there was no statistically significant difference between the groups in terms of preoperative and postoperative AGO values (P: 0.140, P: 0.313). According to Backward: Wald method in multiple regression analysis, in the last step, in patients with POAF; age, preoperative platelet numbers, creatinine levels, presence of peripheral artery disease (PAD) and number of total anastomoses in the patients with POAF were found to be independent risk factors.CONCLUSIONS: In this study, no statistically significant relationship was found between AGO values and the development of POAF. It has been found that preoperative creatinine level and platelet numbers were important in the emergence of POAF in patients a CABG both in the general population and the Diabetes Mellitus patients as a separate subgroup. Additionally, preoperative creatinine, age, total anastomosis number and preoperative platelet number were independent risk factors.

Keywords:

Coronary artery bypass grefting, Postoperative atrial fibrillation, Albumin, Globulin, Albumin globulin ratio,

PDF

___

1. Yedava M, Hughey AB, Crawford TC. Postoperative Atrial Fibrillation: Incidence, Mechanisms, and Clinical Correlates. Heart Failure Clinics. 2016;12(2):299-308.
2. Montrief T, Koyfman A, Long B. Coronary artery bypass graft surgery complications: A review for emergency clinicians. Am J Emerg Med. 2018;36(12):2289-97.
3. Bruno VD, Ascione R. Postoperative atrial fibrillation: Still in search of truth or a neglected complication?. The Journal of Thoracic and Cardiovascular Surgery. 2018;155(1):236-37.
4. Busher JT. Serum albumin and globulin. In: Clinical Methods: The History, Physical, and Laboratory Examinations. Walker HK, Hall WD, Hurst JW (Eds). Butterworth Publishers, a division of Reed Publishing, MA, USA (1990).1990;497-9.
5. Guo HW, Yuan TZ, Chen JX, et al. Prognostic value of pretreatment albumin/globulin ratio in digestive system cancers: A meta-analysis. PLoS One. 2018 ;13(1):e0189839.
6. Akgul E, Parlar AI, Erkul GSA, et al. Investigation of the Effect of Preoperative Hypoalbuminemia, Blood Urea Nitrogen and Creatinine Levels on Postoperative Atrial Fibrillation on Off-Pump Coronary Bypass Surgery Patients. In the Heart Surgery Forum. 2020;23(5):E641-46.
7. Azab B, Bibawy J, Harris K, et al. Value of albumin-globulin ratio as a predictor of all-cause mortality after non-ST elevation myocardial infarction. Angiology. 2013;64(2):137-45.
8. Kirchhof P, Benussi S, Kotecha D, et al. ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal. 2016; 2893‐ 2962.
9. Barbosa RR, Cestari PF, Capeletti JT, et al. Impact of renal failure on in-hospital outcomes after coronary artery bypass surgery. Arquivos Brasileiros de Cardiologia. 2011 97(3):249-53.
10. Raza S, Sabik JF 3rd, Ainkaran P, et al. Coronary artery bypass grafting in diabetics: A growing health care cost crisis. The Journal of Thoracic and Cardiovascular Surgery. 2015;150(2):304-2.e2.
11. Kalus JS, White CM, Caron MF, et al. Indicators of atrial fibrillation risk in cardiac surgery patients on prophylactic amiodarone. The Annals of Thoracic Surgery. 2004;77(4):1288-92.
12. Dobrev D, Aguilar M, Heijman J, et al. Postoperative atrial fibrillation: mechanisms, manifestations and management. Nature Reviews Cardiology. 2019;16(7):417-36.
13. Goldman S. A more aggressive approach for the prevention of postoperative atrial fibrillation is warranted. The Journal of Thoracic Cardiovascular Surgery. 2018;155(1):254-55.
14. Lamm G, Auer J, Weber T, et al. Postoperative white blood cell count predicts atrial fibrillation after cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia. 2006 ;20(1):51-6.
15. Aksoy F, Uysal D, Ibrişim E. Relationship between c-reactive protein/albumin ratio and new-onset atrial fibrillation after coronary artery bypass grafting. Revista da Associação Médica Brasileira. 2020 ;66(8):1070-1076.
16. Fu XX, Zhao N, Dong Q, et al. Interleukin-17A contributes to the development of post-operative atrial fibrillation by regulating inflammation and fibrosis in rats with sterile pericarditis. International Journal of Molecular Medicine. 2015;36(1):83-92.
17. Karabacak K, Kubat E, Akyol FB, et al. The C-reactive protein/albumin ratio as a new predictor for postoperative atrial fibrillation after coronary artery bypass graft surgery. Journal of Cardiac Surgery. 2020;35(10):2747-53.
18. Tousoulis D, Zisimos K, Antoniades C, et al. Oxidative stress and inflammatory process in patients with atrial fibrillation: the role of left atrium distension. International Journal of Cardiology. 2009; 136 : 258-62.
19. Don BR, Kaysen G. Poor nutritional status and inflamation: serum albumin: relationship to inflammation and nutrition. Seminars in Dialysis. 2004;17(6):432-7.
20. Lv GY, An L, Sun XD, et al. Pretreatment albumin to globulin ratio can serve as a prognostic marker in human cancers: a meta-analysis. Clinica Chimica Acta. 2018;476:81- 91.
21. Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutrition Journal. 2010;9:1-16.
22. Wada H, Dohi T, Miyauchi K, et al. Independent and combined effects of serum albumin and C-reactive protein on long-term outcomes of patients undergoing percutaneous coronary intervention. Circulation Journal. 2017;81(9):1293-300.
23. Arques S. Human serum albumin in cardiovascular diseases. European Journal of Internal Medicine. 2018;52:8-12.
24. Auer J, Lamm G, Weber T, et al. Renal function is associated with risk of atrial fibrillation after cardiac surgery. Canadian Journal of Cardiology. 2007;23(11):859-63.
25. Klein IH, Ligtenberg G, Oey PL, et al. Sympathetic activity is increased in polycystic kidney disease and is associated with hypertension. Journal of American Society of Nephrology. 2001;12(11):2427-33.
26. Raza S, Blacstone EH, Houghtaling PL, et al. Influence of Diabetes on Long-Term Coronary Artery Bypass Graft Patency. Journal Of The American College Of Cardiology. 201 7;70(5): 515-24.
27. Goudis CA, Korantzopoulos P, Ntalas IV, et al. Diabetes mellitus and atrial fibrillation: Pathophysiological mechanisms and potential upstream therapies. International Journal of Cardiology. 2015;184:617-22.
28. Carson JL, Scholz PM, Chen AY, et al. Diabetes mellitus increases short-term mortality and morbidity in patients undergoing coronary artery bypass graft surgery. Journal of American College of Cardiology. 2002;40:418-23.
29. Woods SE, Smith JM, Sohail S, et al. The influence of type 2 diabetes mellitus in patients undergoing coronary artery bypass graft surgery: an 8-year prospective cohort study. Chest. 2004;126:1789-95.
30. Rajakaruna C, Rogers CA, Suranimala C, et al. The effect of diabetes mellitus on patients undergoing coronary surgery: a risk adjusted analysis. The Journal of Thoracic and Cardiovascular Surgery. 2006;132:802-10.
31. Kubal C, Srinivasan AK, Grayson AD, et al. Effect of risk-adjusted diabetes on mortality and morbidity after coronary artery bypass surgery. The Annals of Thoracic Surgery. 2005;79:1570-6.
32. Lazar HL, Chipkin SR, Fitzgerald CA, et al. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation. 200430;109(12):1497-502.
33. Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. The Journal Thoracic and Cardiovascular Surgery. 2008;136(3):631-40.
34. Folla CO, Melo CC, Silva RC. Predictive factors of atrial fibrillation after coronary artery bypass grafting. Einstein (Sao Paulo). 2016;14(4):480-85.
35. Koenen RR. The prowess of platelets in immunity and inflammation. Thrombosis and Haemostasis. 2016;116(4):605-12.